Medicines Q&As
Q&A 163.2
What is the risk of gastrointestinal bleeding associated with
selective serotonin reuptake inhibitors (SSRIs)?
Prepared by UK Medicines Information (UKMi) pharmacists for NHS healthcare professionals
Before using this Q&A, read the disclaimer at www.ukmi.nhs.uk/activities/medicinesQAs/default.asp
Date prepared: 21 January 2013
Background
Various reviews and meta-analyses (1-8) have indicated that there is a link between selective
serotonin reuptake inhibitor (SSRI) use and gastrointestinal (GI) bleeding, particularly upper GI
bleeding (3,4,7,8). An increased risk of bleeding has been noted in elderly patients (7), and with the
concomitant use of SSRIs and non-steroidal anti-inflammatory drugs (NSAIDs) (2-5,7,8).
Serotonin has an important role in the haemostatic response to injury by promoting platelet
aggregation (1,9,10). SSRIs inhibit the uptake of serotonin into platelets which might lead to an
increased risk of abnormal bleeding (1,9,10). The increase in gastric acid secretion caused by SSRIs
could also increase the risk of ulcer development and GI bleeding (8). Due to reports of bleeding,
including GI bleeding, manufacturers advise caution in patients with a history of bleeding disorders
and in those taking SSRIs concomitantly with antiplatelets and other drugs that might increase the risk
of bleeding (11-16).
Answer
To determine whether SSRIs and venlafaxine (a serotonin and noradrenaline re-uptake inhibitor
[SNRI]) are associated with upper GI tract bleeding, de Abajo and colleagues (17) conducted a casecontrol study in which details of case and control patients were drawn from a database used by
general practitioners in the UK to store clinical information about their patients. Several similar casecontrol studies had been conducted in the past, but this one differed in that as well as aiming to
identify subgroups of patients at an increased risk of bleeds with SSRIs, it sought to determine
whether acid suppressing agents were effective in minimising this risk.
Patients with upper GI tract bleeding (n=1321) who had been referred to a hospital or consultant and
10,000 control subjects were matched for age, sex and calendar year of the index date. For cases,
the index date was the date of first symptoms or first diagnosis. For controls, a date within the study
period was assigned randomly. Patients were defined as ‘current users’ if their prescribed
antidepressants lasted until the index date or were discontinued within 30 days of the index date.
Although the three-fold increased risk of upper GI bleeding with SSRIs reported in a previous study
(1) by the same authors was not seen again, percentages of current users of SSRIs or venlafaxine
were found to be higher for case subjects than controls (5.3% versus 3.0% [SSRIs]; adjusted odds
ratio [OR] 1.6; 95% confidence interval [CI]: 1.2-2.1; and 1.1% versus 0.3% [venlafaxine]; adjusted
OR 2.9; 95% CI: 1.5-5.6). The odds ratios were adjusted for age, sex, calendar year, smoking status,
alcohol intake, antecedents of GI disorder and concomitant use of NSAIDs, systemic corticosteroids,
warfarin, low-dose aspirin and other antiplatelet drugs. The risk of upper GI tract bleeding was
elevated further in patients receiving concomitant NSAIDs (OR 4.8; 95% CI: 2.8-8.3) or corticosteroids
(OR 4.0; 95% CI: 1.3-12.3) (17).
Interestingly, de Abajo and colleagues (17) noted that acid suppressing agents protected against GI
bleeding in patients receiving either serotonin reuptake inhibitors (SRIs [SSRIs or SNRIs]) or both
SRIs and NSAIDs (OR 2.0; 95% CI: 1.5-2.8 [SRI only] and OR 9.1; 95% CI: 4.8-17.3 [SRI + NSAID] in
non-users of acid suppressors and OR 1.4; 95% CI: 0.8-2.3 [SRI only] and OR 1.1; 95% CI: 0.3-3.4
[SRI + NSAID] in current users of acid suppressors). In context, this would mean that for every 2000
patients receiving an SRI only, or every 250 patients receiving an SRI with an NSAID, without GI
protection, one patient would have an upper GI bleed. With GI protection, 5000 or more patients
would need to be treated with an SRI or SRI with an NSAID in order for one case to be attributed to
From the NHS Evidence website www.evidence.nhs.uk
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Medicines Q&As
these drugs. Another study found that concomitant therapy with a proton-pump inhibitor (PPI)
significantly reduced the modest risk of SSRI-related upper GI bleeding (OR 0.39; 95% CI: 0.160.94)(18). Before these studies, gastro-protective agents such as H2 receptor antagonists, PPIs or
misoprostol had not been shown to reduce the risk of GI bleeds associated with SSRIs alone (4,6) or
in combination with NSAIDs (6).
Results from cohort and case-control studies with similar objectives and comparable outcomes to
those of de Abajo and colleagues (17) are shown in Table 1. The majority of these concluded that
SSRIs are associated with an increased risk of GI bleeding (1,10,17-19,21,), and some found this risk
to be potentiated by the concomitant use of NSAIDs (1,10,17,19,20). Others found no significant
association between GI bleeding and SSRI use (22,23) or no potentiation of this effect with
concomitant SSRI and NSAID use (18,24).
Comparison of these results is complicated by the fact that the studies differed with regard to
adjustment for confounding factors. Studies have shown that, in addition to concomitant medication,
alcohol intake (25) and H.pylori status (26) are important to take into account when determining the
effects of SSRIs on the risk of GI bleeding.
Patient age and the degree to which different antidepressants inhibit serotonin reuptake were factors
of interest in one observational study in 317,824 elderly patients which looked at upper GI bleeding
rates. The antidepressants these patients were taking were split into 2 groups: those with low
inhibition of serotonin reuptake (e.g. nortriptyline, doxepin, trazodone) and those with high inhibition of
serotonin reuptake (e.g. paroxetine, sertraline, fluoxetine) (27). Absolute differences between these
antidepressant groups were greatest (and statistically significant) for patients aged 80 and over
(bleeding rates for high versus low inhibition: 14.7 per 1000 person years versus 10.6 per 1000
person years; number needed to harm [NNH] =244), and those with previous upper GI bleeding
(bleeding rates for high versus low inhibition: 40.3 per 1000 person years versus 28.6 per 1000
person years; NNH=85) (27).
A recent study, in which the medical records of 36,389 patients were examined, also found the
adjusted relative risk for GI bleeds to be higher in patients receiving antidepressants with a higher
affinity for the serotonin transporter (relative risk for high versus low-affinity antidepressants = 1.17
(95% CI 1.02-1.34). This study was of particular interest because it was restricted to patients with
major depressive disorder, thereby reducing the risk of confounding by indication. Patients in this
study received monotherapy with a SSRI, serotonin-norepinephrine reuptake inhibitor or other newgeneration antidepressant (28).
In a case-control study (19), the risk of upper GI bleeding was found to be greatest in patients who
had recently (within the last 0-30 days) started SSRI use. This finding is supported by another study,
which found that mortality was increased in the 30 days following hospital admission for peptic ulcer
bleeding in patients who had started SSRIs within 60 days of admission (particularly those over 80
years). In this study, long-term exposure to SSRIs, alone or with NSAIDs did not increase 30-day
mortality after peptic ulcer bleeding (29).
For a rare condition, the OR approximates the relative risk (30). Therefore, in Table 1, some results
are reported as an OR and others as relative risk (both versus non-use of the specified medicines), as
they appeared in the original papers.
From the NHS Evidence website www.evidence.nhs.uk
2
Medicines Q&As
Table 1. Studies examining the possibility of an association between SSRI use and upper GI bleeding.
Study and type
Number of
Current use
Risk (odds ratio [OR],
study
relative risk [RR] or other)
participants
versus non-use
c
de Abajo FJ and Garcia1321 patients
SRIs (includes SSRIs and
OR, adjusted (95% CI):
a
Rodriguez LA. Arch Gen Psych with upper GI
a
venlafaxine) only :
SRIs only :1.8 (1.1-2.9)
2008;65(7):795-803 (17)
bleeding/
22 cases, 105 controls
SRIs plus NSAIDs: 4.8
Nested case-control study
perforation
b
(2.8-8.3)
NSAID
only
:
173
cases,
referred to
642
controls
OR (95% CI): with gastro
consultant or
NSAID and SRIs:
protection:
hospital
a
23 cases, 44 controls
10,000 controls
SRIs only :1.4 (0.8-2.3)
SRIs plus NSAIDs: 1.1
(0.3-3.4)
With no gastro
protection/remote use:
Conclusions
SSRIs, and venlafaxine,
increase the risk of upper GI
tract bleeding. This risk was
increased further by the
concomitant use of NSAIDs
and SRIs.
Acid suppressing agents
lowered the risk of upper GI
tract bleeding associated with
SRIs +/- NSAIDs.
a
SRIs only : 2.0 (1.5-2.8)
SRIs plus NSAIDs: 9.1
(4.8-17.3)
Dall M et al. Clin Gastroenterol
Hepatol 2009;7:1314-21(19)
Case-control study
3652 patients
with serious
upper GI
bleeding
36,502 controls
SSRIs (current use):
377 cases, 1809 controls
SSRI (recent use):
77 cases, 381 controls
SSRI (past use):
360 cases, 2484 controls
SSRI alone: 40 cases,
326 controls
NSAID only: 625 cases,
2635 controls
NSAID and SSRI:
99 cases, 183 controls
NSAID, SSRI, and low-dose
aspirin: 38 cases,
40 controls
PPI (current use):
73 cases, 234 controls
d
OR, adjusted (95% CI):
SSRIs (current use): 1.70
(1.49-1.95)
SSRIs (recent use): 1.86
(1.41-2.5)
SSRIs (past use): 1.24
(1.09-1.42)
SSRI only: 1.7 (1.01-2.8)
NSAID only: 4.3 (3.7-5.1)
NSAID plus SSRI: 8.0
(4.8-13)
NSAID, SSRI plus low-dose
aspirin: 28 (7.6-103)
PPI (current use): 0.96
(0.50-1.82)
From the NHS Evidence website www.evidence.nhs.uk
SSRI use was associated with
upper GI bleeding. This risk
was increased further by the
concomitant use of NSAIDs
and SSRIs, and further still by
adding in low-dose aspirin to
treatment with NSAIDs and
SSRIs.
Among users of SSRIs, the
risk of upper GI bleeding was
found to be highest in those
who had recently started
taking SSRIs.
PPIs protected against upper
GI bleeding in users of SSRIs.
3
Medicines Q&As
SSRI onlya: 284 cases,
931 controls
NSAID onlye:1714 cases,
3089 controls
NSAID and SSRI: 157 cases,
159 controls
SSRI (included venlafaxine):
111 cases, 136 controls
NSAID: 42 cases, 38 controls
OR, adjustedf (95% CI):
SSRIs, excluding NSAID
users:1.30 (1.13-1.50)
SSRI and NSAID:4.19
(3.30-5.31)
NSAID only:2.83 (2.65-3.03)
OR (95% CI):
SSRIs (lower or upper
bleeds) 1.5 (1.2-2.0) p=0.003
SSRIs (lower bleeds): 1.8
(1.2-2.8) p=0.005
SSRIs (upper bleeds): 1.3
(0.83-1.9) p=0.281
1552 patients
with upper GI
bleeding
68,590 controls
SSRI only: 62 cases,
1881 controls
NSAID only: 263 cases,
5266 controls
SSRI and NSAID: 23 cases,
337 controls
SSRI and PPI:
6 cases, 369 controls
OR, adjustedg (95% CI):
SSRI only: 1.43 (1.09-1.89)
NSAID only: 2.62 (2.26-3.03)
SSRI plus NSAID: 3.17
(2.01-5.00)
SSRI plus PPI: 0.56
(0.24-1.30)
Users of
antidepressants:
26,005
Control: No
antidepressants/
no NSAIDs
(numbers not
given)
SSRI onlya: 55 cases,
17,320 persons
SSRI and NSAID only:
17 cases, 4107 persons
Other antidepressants onlye:
9 cases, 4436 persons
Observed/expected ratio
(95% CI)
SSRIs onlyb: 3.6 (2.7-4.7)
Other antidepressants
onlye:1.7 (0.8-3.1)
SSRI and NSAID:12.2
(7.1-19.5)
Helin-Salmivaara A et al. Eur J
Clin Pharmacol 2007;63:403-8
(21)
Case-control study
9191 cases with
serious upper GI
events
41,780 controls
Wessinger S et al. Aliment
Pharmacol Ther 2006;23:93744 (20)
Case-control study
579 cases
hospitalised with
acute GI
haemorrhage
1000 controls
Targownik LE et al. Am J
Gastroenterol 2009;104:14751482 (18)
Case-control study
Dalton S et al. Arch Intern Med
2003;163:59-64 (10)
Population based cohort
study
From the NHS Evidence website www.evidence.nhs.uk
Compared with NSAID use
alone, the concurrent use of
SSRIs and NSAIDs is
associated with a moderate
excess relative risk of a
serious upper GI event.
Patients admitted with GI
haemorrhage (lower or upper)
were more likely to be taking
SSRIs than controls. SSRI use
was statistically significantly
greater among cases of lower
GI bleeding, but not among
those of upper GI bleeding.
SSRI use was associated with
a modest increase in the risk
of upper GI bleeding.
PPIs reduced the risk of SSRIassociated upper GI bleeding
by approximately 60% (OR,
0.39; 95% CI: 0.16-0.94). The
risk of developing upper GI
bleeding in patients using both
an SSRI and an NSAID was
not increased significantly
above that in patients using
only an NSAID
SSRIs, but not other
antidepressants, increased the
risk of upper GI bleeding, and
this effect is potentiated by
concurrent use of NSAIDs.
4
Medicines Q&As
de Abajo FJ et al.
Br Med J 1999;319:1106-9 (1)
Population based casecontrol study
Dunn NR et al.
Br Med J2000;320:1405-6 (22)
Population based cohort
study
Vidal X et al.
Drug Safety 2008;(312):159-68
(23)
Case-control study
Tata LJ et al.
Aliment Pharmacol Ther
2005;22:175-81 (24)
Case-control study
1651 cases of
upper GI
bleeding
248 cases of
ulcer perforation
10,000 controls
SSRIs: 237,609
patient months
of exposure
Comparator
drugs
(moclobemide
and salmeterol):
205,431 patient
months of
exposure
2813 cases of
upper GI
bleeding
7193 matched
controls
NSAIDs onlye: 295 cases,
652 controls
SSRIs onlya: 38 cases,
93 controls
NSAIDs & SSRIs: 16 cases,
9 controls
SSRIsi: 103 cases
Comparator drug: 72 cases
RR, adjustedh (95% CI):
SSRIs onlya: 2.6 (1.7-3.8)
SSRI and NSAID:15.6
(6.6-36.6)
SSRIs moderately increase the
risk of upper GI bleeding.
Concurrent use of NSAIDs and
SSRIs greatly increases the
risk of upper GI bleeding.
Rate ratio (95% CI) versus
comparator group:
1.24 (0.91-1.70)
Found no evidence to suggest
that SSRIs are more likely to
cause GI bleeding than
comparator drugs.
High affinity SRIj (not necessarily
alone): 84 cases, 160 controls
NSAID and high affinity SRI:
41 cases, 26 controls
No significant association was
found between use of SRIs
and risk of upper GI bleeding.
The OR among concurrent
users of a high-affinity SRI and
an NSAID did not differ from
that of users of NSAIDs alone.
The risk of GI bleeding with
SSRI use was slightly
increased in patients aged
over 70 compared to those
aged under 70.
11,261 cases
with upper GI
bleeding
53,156 controls
SSRI onlya: 253 cases,
522 controls
NSAID onlyb: 1871 cases,
4700 controls
SSRI and NSAID:92 cases,
168 controls
OR, adjustedk (95% CI):
High-affinity SRIs: 1.24
(0.88-1.76)
High-affinity SRI and NSAID:
8.32 (4.69-14.76)
NSAIDs without high-affinity
SRI: 7.82 (6.79-9.00)
Analysis within the SSRI
group:
SSRIs (>70 years):1.57
(0.97-2.56)
SSRIs (<70 years):1.04
(0.63-1.73)
OR (95% CI):
SSRI onlya: 2.63 (2.24-3.07)
SSRI and NSAID: 2.93
(2.25-3.82)
NSAID onlyb: 2.19
(2.05-2.33)
From the NHS Evidence website www.evidence.nhs.uk
The risk of GI bleeding is not
substantially increased when
NSAIDs and SSRIs are
prescribed together when
compared to alone.
5
Medicines Q&As
a. No other antidepressants or NSAIDs used.
b. No antidepressants used.
c. Adjusted for smoking status, alcohol intake, antecedents of GI disorder, and concomitant use of other medications associated with upper GI tract bleeding
(NSAIDs, systemic corticosteroids, warfarin, low-dose aspirin and other antiplatelet drugs).
d. Adjusted for use of aspirin and PPIs, alcohol abuse, cerebral ischemia, stroke, use of warfarin, clopidogrel, dipyridamole, and corticosteroids, prior
Helicobacter eradication, peptic ulcer, upper GI bleed and cirrhosis.
e. No SSRIs used.
f. Adjusted for year of birth, sex, hospital catchment area, diabetes mellitus, rheumatoid arthritis, coronary artery disease, hypertension, asthma, cardiac
insufficiency, use of H2 antagonist, PPI or plain misoprostol in the period extending from five years to 90 days prior to the index date (as a proxy for past GI
morbidity). Also, use of H2 antagonist, plain misoprostol, PPI, warfarin, clopidogrel, oral or inhaled glucocorticoid or tramadol in the 90-day period immediately
prior to the index date as well as any in-patient period lasting at least 7 days, in-patient period for an injury and a hospitalisation for hip or knee arthroplasty.
g. Adjusted for specific medical comorbidities, use of other medications believed to affect the risk of upper GI complications, and history of GI disease.
h. Adjusted for sex, age, year, antecedents of upper GI disorders, smoking status, and use of aspirin, anticoagulants, or steroids.
i. Fluvoxamine, fluoxetine, paroxetine, sertraline and included nefazodone (SNRI).
j. Included fluoxetine, paroxetine, sertraline and clomipramine, but not fluvoxamine, citalopram or venlafaxine.
k. Adjusted for history of peptic ulcer, dyspepsia, upper GI bleeding, diabetes mellitus, smoking habit, alcohol consumption and use of antacids, PPIs,
sucralfate, nitrates, systemic NSAIDs, topical NSAIDs, analgesics, antiplatelet drugs, dihydropyridine calcium antagonists and HMG Co-A reductase inhibitors
in the week before the GI bleeding symptoms started.
From the NHS Evidence website www.evidence.nhs.uk
6
Medicines Q&As
Summary
The results from most, but not all observational studies suggest that there is an association between
the use of SSRIs and GI bleeds. One study indicated that patients taking SSRIs have a three-fold
increased risk of developing a GI bleed compared to patients not taking SSRIs and who have no risk
factors for GI bleeding. However, recent studies have found the risk to be more modest. In general,
comparison of the results of studies on SSRI use and GI bleeding is complicated by the fact that the
confounding factors taken into account differ in each case. Some studies have found the use of
SSRIs with concomitant NSAIDs to increase the risk of GI bleed further. Being over the age of 80 or
having a previous history of GI bleeding may also add to the risk of GI bleeding with SSRIs and there
is some evidence that the risk of GI bleeding is higher in patients who have just started taking SSRIs.
If an SSRI is required in a patient at high risk of a GI bleed then the use of a gastro-protective agent
could be considered. Studies have shown the use of acid suppressing drugs, e.g. PPIs, to be
protective against GI bleeds in patients receiving single-therapy SSRI or combined NSAID and SSRI
treatment.
Limitations
Studies that have looked at the risk of GI bleeds in SSRI users have differed with respect to their
outcomes and the confounding factors taken into account.
References
1. de Abajo FJ, Garcia Rodriguez LA, Montero D. Association between selective serotonin
reuptake inhibitors and upper gastrointestinal bleeding: population based case-control
study. Br Med J 1999;319:1106-9.
2. Mort JR, Aparasu RR, Baer RK. Interaction between selective serotonin reuptake
inhibitors and nonsteroidal anti-inflammatory drugs: review of the literature. Pharmacother
2006;26(9):1307-13.
3. Loke YK, Trivedi AN, Singh S. Meta-analysis: gastrointestinal bleeding due to interaction
between selective serotonin uptake inhibitors and non-steroidal anti-inflammatory drugs.
Aliment Pharmacol Ther 2008;27:31-40.
4. Yuan Y, Tsoi K, Hunt RH. Selective serotonin reuptake inhibitors and risk of upper GI
bleeding: confusion or confounding? Am J Med 2006;119:719-27.
5. Turner MS, May DB, Arthur RR et al. Clinical impact of selective serotonin reuptake
inhibitors therapy with bleeding risks. J Intern Med 2007;261:205-13.
6. Paton C, Ferrier IN. SSRIs and gastrointestinal bleeding. Br Med J 2005;331:529-30.
7. de Abajo FJ, Montero D, Garcia Rodriguez LA et al. Antidepressants and risk of upper
gastrointestinal bleeding. Basic Clin Pharmacol Toxicol 2006;98:304-10.
8. Andrade C, Sandarsh S, Chethan KB et al. Serotonin reuptake inhibitor antidepressants
and abnormal bleeding: A review for clinicians and a reconsideration of mechanisms. J
Clin Psychiat 2010;71(12):1565-75.
9. van Walraven C, Mamdani MM, Wells PS et al. Inhibition of serotonin reuptake by
antidepressants and upper gastrointestinal bleeding in elderly patients: retrospective
cohort study. Br Med J 2001;323:1-6.
10. Dalton SO, Johansen C, Mellemkjoer L et al. Use of selective serotonin reuptake
inhibitors and risk of upper gastrointestinal tract bleeding. A population-based cohort
study. Arch Intern Med 2003;163:59-64.
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7
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associated with selective serotonin reuptake inhibitors and venlafaxine therapy. Arch Gen
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associated with a modest increase in the risk of upper gastrointestinal bleeding. Am J
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selective serotonin reuptake inhibitor use and serious upper gastrointestinal bleeding.
Clin Gastroenterol Hepatol 2009;7:1314-21.
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inhibitors in patients admitted with gastrointestinal haemorrhage: a multicentre
retrospective analysis. Aliment Pharmacol Ther 2006;23:937-44.
21. Helin-Salmivaara A, Huttunen T, Grönroos GMT et al. Risk of serious upper
gastrointestinal events with concurrent use of NSAIDs and SSRIs: a case-control study in
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such bleeding. Br Med J 2000;320:1405-6.
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of serotonin reuptake inhibition by antidepressants. Drug Saf 2008;31:159-68.
24. Tata LJ, Fortune PJ, Hubbard RB et al. Does concurrent prescription of selective
serotonin reuptake inhibitors and non-steroidal anti-inflammatory drugs substantially
increase the risk of upper gastrointestinal bleeding? Aliment Pharmacol Ther
2005;22:175-81
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serotonin receptor antagonist therapy: a new look. Br J Clin Pharmacol 2008;66:76-81.
26. Dall M, Schaffalitzky de Muckadell OB, Moller Hansen J et al. Helicobacter pylori and risk
of upper gastrointestinal bleeding among users of selective serotonin reuptake inhibitors.
Scand J Gastroenterol 2011;46:1039-44.
27. van Walraven C, Mamdani MM, Wells PS et al. Inhibition of serotonin reuptake by
antidepressants and upper gastrointestinal bleeding in elderly patients: retrospective
cohort study. Br Med J 2001;323:655-8.
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29. Gasse C, Christensen S, Riis A et al. Preadmission use of SSRIs alone or in combination
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From the NHS Evidence website www.evidence.nhs.uk
8
Medicines Q&As
Quality Assurance
Prepared by
Alex Bailey, Information Scientist, Welsh Medicines Information Centre
Date Prepared
21 January 2013
Checked by
Fiona Woods, Director, Welsh Medicines Information Centre
Date of check
21 January 2013
Search strategy
 Embase (exp Serotonin Uptake Inhibitor/ae, to [Adverse Drug Reaction, Drug Toxicity] AND
exp Gastrointestinal Hemorrhage/) limited to human and english language
 Medline (exp Serotonin Uptake Inhibitors/ae, to [Adverse Effects, Toxicity] AND exp
Gastrointestinal Hemorrhage/) limited to human
 IDIS Drug(s): ("antidepressants-ssris 28160700" and Descriptors: "side ef digestive 78" AND
All fields: “bleeding” )
 Micromedex (Searched under individual SSRI names in DrugDex and Martindale, also
checked Drug Consults)
 EMC (Searched under individual SSRI names)
 In-house database/ resources (SSRI and bleed*)
 NeLM (ssri* AND bleed*; selective serotonin reuptake, ssri, gastrointestinal bleed*) (2008-12)
 Pharmline (for previous version) “serotonin reuptake inhibitors” AND “haemorrhagegastrointestinal”
 Meyler’s Side Effects of Drugs (15th ed) selective serotonin re-uptake inhibitors
 Stockley’s (online) ssris warfarin
From the NHS Evidence website www.evidence.nhs.uk
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